Which antidepressants, such as Selective Serotonin Reuptake Inhibitors (SSRIs), Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs), Tricyclic Antidepressants (TCAs), and Monoamine Oxidase Inhibitors (MAOIs), can cause vertigo?

Antidepressants That Cause Vertigo

Paroxetine, fluvoxamine, and sertraline are the antidepressants most commonly associated with vertigo, particularly during discontinuation, while venlafaxine among SNRIs has a higher risk of dizziness and vertigo as side effects. 1

SSRIs and Vertigo

During Treatment

SSRIs can cause vertigo both as a side effect during treatment and as a withdrawal symptom:

• Common side effects during treatment:
  • Dizziness is among the most commonly reported adverse effects of SSRIs 1
  • All second-generation antidepressants (including SSRIs, SNRIs) can cause dizziness as a side effect 1
  • Approximately 63% of patients on second-generation antidepressants experience at least one adverse effect, with dizziness being among the common ones 1

During Discontinuation

A discontinuation syndrome characterized by vertigo and other symptoms is particularly associated with:

• Paroxetine - Most strongly associated with discontinuation syndrome including vertigo 1
• Fluvoxamine - Associated with discontinuation syndrome to a lesser extent than paroxetine 1
• Sertraline - Also associated with discontinuation syndrome to a lesser extent 1

The vertigo experienced during SSRI discontinuation is typically exacerbated by head movement, suggesting a vestibular origin. This occurs because the vestibular nucleus complex has abundant serotonin receptors, and abrupt withdrawal disrupts the function of vestibular neurons bilaterally 2.

SNRIs and Vertigo

SNRIs also commonly cause dizziness and vertigo:

• Venlafaxine and duloxetine have higher rates of adverse effects compared to SSRIs 1
• Adverse effects of SNRIs include dizziness, which can manifest as vertigo 1
• Venlafaxine in particular has been associated with discontinuation symptoms including vertigo 1

TCAs and MAOIs

While the evidence is less specific regarding vertigo with older antidepressants:

• TCAs have higher discontinuation rates due to adverse effects compared to SSRIs (NNH 4-30 for TCAs vs 20-90 for SSRIs) 1
• MAOIs can cause dizziness and are associated with significant drug interactions that may exacerbate balance problems 1

Mechanism of Vertigo with Antidepressants

Vertigo from antidepressants occurs through several mechanisms:

1. Direct effect on vestibular system: Serotonin receptors in the vestibular nucleus complex are affected by changes in serotonin levels 2

2. Discontinuation syndrome: Particularly with shorter-acting SSRIs, abrupt withdrawal causes sudden decrease in serotonin in the vestibular nucleus, disrupting function 2

3. Drug interactions: Combining serotonergic medications can increase risk of serotonin syndrome, which includes dizziness among its symptoms 1

Clinical Management Considerations

When prescribing antidepressants where vertigo is a concern:

• For patients at high risk of vertigo: Consider citalopram/escitalopram which may have lower propensity for discontinuation symptoms 1

• When discontinuing SSRIs/SNRIs: Implement gradual tapering rather than abrupt cessation to minimize vertigo and other discontinuation symptoms 1, 3

  • For sertraline: A tapering duration of 10-14 days is recommended after long-term use 4
  • For paroxetine: Even more gradual tapering is needed due to higher risk of discontinuation syndrome 5

• Monitoring: Assess for dizziness/vertigo at each visit, especially after dose changes 4

• Patient education: Inform patients about potential for vertigo, especially with paroxetine, fluvoxamine, and sertraline 1

Special Populations

• Elderly patients: More susceptible to vertigo from antidepressants; preferred agents include citalopram, escitalopram, and sertraline 1

• Patients with history of vestibular disorders: May be more sensitive to the vertigo-inducing effects of antidepressants 6

Remember that while vertigo can be distressing, it rarely represents a direct threat to life. However, it can indirectly cause harm through falls and injuries, particularly in elderly patients 7.